The Heart Healers (15 page)
Authors: James Forrester
As early as 1899 researchers in Geneva had demonstrated that an electrical current could restore normal rhythm during ventricular fibrillation in dogs. The observation meant little to medicine until the development and widespread use of the electrocardiogram in the 1920s. Until the ECG, doctors were unaware that ventricular fibrillation was the rhythm of sudden death. The leader in ventricular fibrillation research in animals in the years surrounding World War II was Dr. Carl Wiggers of Western Reserve in Cleveland. Wiggers had developed a method of defibrillation by delivering an electric shock using two paddles that he applied directly to the heart of his experimental dogs. Beck demanded that Wiggers’s apparatus be immediately brought to his operating room. Beck waited. And waited. Imagine squeezing the heart sixty times a minute, with no realistic hope of saving the child. After forty-five minutes, when the device arrived, he could barely open and close his hand. Beck wiped off the paddles—no sense giving his patient an infection—and immediately applied an electrical current directly to the boy’s quivering, lifeless heart using Wiggers’s dog paddles. Ventricular fibrillation persisted. For millennia, mankind had tried to restore life to the dead. How grandiose of Claude Beck to imagine that he could accomplish that which was reserved to the gods. It would not be permitted on a Cleveland morning.
But Beck was not one to concede failure. He called for procaine, a drug that suppresses ventricular arrhythmias. He injected the drug directly into the boy’s right atrium and continued squeezing to distribute the drug throughout the heart.
Paddles applied again, a second shock, irregular twitches morphing into a few rapid feeble contractions, more regular now, a heart struggling to rise from a knockout blow, as if unwilling to be counted out just yet. Beck returned to squeezing the heart, urging his staggering gladiator to continue this fight, pausing every few moments to see if the heart continued to beat on its own. With each check, the boy’s heart seemed stronger, stronger again … in about five minutes, it generated a palpable blood pressure with no help from Beck’s aching fingers.
Claude Beck had accomplished the impossible. He had miraculously restored life to a boy who was dead. He had proven that the human heart could be restarted after it stopped beating, that the suddenly dead could be restored to life. An Alexander the Great cutting through the Gordian knot rather than untying it, Beck had solved the mystery of cardiac resuscitation with a single definitive slash of his scalpel. Today resuscitation is a commonplace occurrence in hospitals around the world. I can testify that the incomparable profound emotion that engulfed Beck is undiminished today when one is successful. Imagine for a moment my elation, my relief had I restored life to Willie the Phillie on that Philadelphia morning long ago. But Claude Beck was the first, and in that one brief, luminous moment, he had achieved mankind’s dream of two millennia, so clearly first given voice in the Christian tradition when Jesus restores life to Lazarus with the words, “I am the resurrection and the life” (John 11).
* * *
IN THE AMBULANCE
Fabrice Muamba received twelve more defibrillation shocks, as resuscitation continued without success. He was still dead on arrival at the hospital. In the coronary care unit, intravenous lines, intubation with ventilation, and cardiac drugs were given in a more controlled environment, and defibrillation was repeated. Still no response.
At seventy-five minutes after his cardiac arrest, with hope for Muamba’s survival nearly extinguished, the resuscitation team delivered another defibrillator shock. Fabrice Muamba’s heart started beating. The link between Claude Beck’s fourteen-year-old boy to Fabrice Muamba was complete.
In an emotional interview, the soccer club’s physician who accompanied Muamba stood astonished at his bedside: “It was forty-eight minutes from when he collapsed to reaching the hospital and a further thirty minutes after that. He was, in effect, dead at that time. We were fearing the worst and didn’t think we would get the recovery we had. It’s incredible.”
In the Congo, Football Association president Omari Selemani said the national hero midfielder had the support of “65 million Congolese.” But was the good news really bad news? Would Fabrice Muamba’s brain still function? Muamba was put into therapeutic hypothermia in intensive care to let his brain recover.
Dr. Andrew Deaner, the doctor who had come out of the stands, related that moment that as a doctor you can never forget: “Two hours after [regaining consciousness] I whispered in his ear, ‘What’s your name?’ and he said, ‘Fabrice Muamba.’ I said, ‘I hear you’re a really good footballer’ and he said, ‘I try.’ I had a tear in my eye.”
* * *
CLAUDE BECK’S DECISIVE
act teaches us one common path to scientific breakthroughs. Revolutions occur when happenstance opens a door just a crack, and a unique individual standing at the door glimpses a shimmering possibility that the rest of humanity has missed. Looking at shrapnel projecting from hearts, Dwight Harken intuited opportunity where others saw hopelessness. Beck’s discovery required a thoracic surgeon, an open chest, an open mind, knowledge of Wiggers’s research, a defibrillator system near the surgical suite, and the power to demand its instant delivery. When all those factors came together at one moment in time, Claude Beck seized that moment. Louis Pasteur, who discovered that germs are the cause of infection, summarized this profound scientific insight in five words, “Chance favors the prepared mind.” Soon after Beck described his experience, every operating room had a defibrillator.
In his own hospital, Beck became enraptured with the combination of manual cardiac massage followed by electrical defibrillation. In June 1955, sixty-five-year-old physician Albert Ransone came to Cleveland’s Western Reserve Hospital for a preoperative ECG before his scheduled gall bladder surgery. While in the waiting room he complained of chest pain, then suddenly collapsed and died in the waiting room. Claude Beck and his associate Dr. David Leighninger were nearby. Rushing to his side, without removing his shirt, they immediately slashed through Ransone’s chest wall between the fourth and fifth ribs, pried the ribs apart, forced a hand through the incision, gripped Ransone’s lifeless heart, and began rhythmic manual cardiac massage. They shouted for someone to bring the defibrillator from the operating room. At the same time others on Beck’s team initiated respiratory support. After twenty-five minutes of manual compression of the heart, the defibrillator arrived. Beck was ready. Two paddles delivered an electric shock. It took three shocks, but they restored a normal heart rhythm. But would Dr. Ransone regain consciousness? Would he ever be able to return to the practice of medicine? No one had ever resuscitated a patient outside the operating room, so no one knew. Dr. Ransone completed the miracle. He survived, with his brain intact.
Beck’s manuscript recounting this astounding “man-on-the-street” resuscitation struck the medical world like lightning in the midst of a thunderstorm, illuminating the entire landscape of surgery and medicine. He concluded his manuscript with an extraordinarily prescient vision of the future: “This one experience indicates that resuscitation from a fatal heart attack is not impossible and might be applied to those who die in hospital and perhaps to those who die outside hospital.” If you could defibrillate a heart in the operating room, you could do it on the hospital ward. If you could defibrillate in the hospital, what about on a busy street or in a crowded stadium?
But resuscitating in the operating room was far different from anyplace else. Only in the operating room did you have an open chest. Beck had a solution for that, too. On threat of being fired on the spot, he demanded that each of his trainees carry a scalpel in their white coat pocket. So, soon around the nation, every surgeon’s jacket pocket had a scalpel at the ready. Mercifully this brief fad, which resembled a chaotic Aztec ritual, disappeared suddenly with the arrival of external defibrillators. At Harvard, however, we liked to say that only a fool falls asleep in a cardiology conference with Dwight Harken in the room. Years later, Johns Hopkins Chief of Cardiology Richard Ross’s favorite apocryphal story was that he awoke from a fainting spell to see a Hopkins cardiac surgeon with a scalpel poised above his chest. I countered that during an academic turf war with our cardiac surgeon at my hospital, I had the identical experience, except I hadn’t fainted.
And the Rest of the Story? Dr. Ransone was hospitalized for eleven days for his myocardial infarction (heart attack), then returned to his practice in Florida. Years later one of the participants in Dr. Ransone’s resuscitation decided to track down their original patient. Dr. Ransone had outlived Claude Beck. It was not even close … he lived another twenty-eight years, and died at age ninety-three.
* * *
BY THE MORNING
of March 19, two days after his cardiac arrest, Fabrice Muamba’s heart was in a normal rhythm without medication, and he was able to move his arms and legs. By the fourth hospital day his doctors’ press release was one of those classic understatements that make Americans so fond of the British. They quite seriously told the waiting press that Muamba had “exceeded our expectations” in his recovery. He received what he affectionately calls his second heart, an implantable cardioverter defibrillator (ICD), and was discharged a day short of a month after his collapse.
His interviews after discharge are emotionally touching even to non-soccer fans. Will he return to the pitch? It is too early to say, but his doctors have not ruled it out. “It all depends on my heart rhythm … If it comes back to normality, we’ll see what the specialist says regarding me playing again,” Muamba said.
Two weeks after his hospital discharge Muamba wended his way, smiling broadly, glassy-eyed, arms raised in gratitude, to the center of Bolton’s home stadium turf, amid the tears and raucous cheers of thousands who knew they were witnessing a miracle. And the opponent that day? Tottenham Hotspur. A life that ended a month earlier face down on Tottenham turf had come full circle. What goes around comes around. Fabrice Muamba, meet Dr. Claude Beck.
Reasonable people adapt themselves to the world. Unreasonable people attempt to adapt the world to themselves. All progress, therefore, depends on unreasonable people.
—GEORGE BERNARD SHAW, IRISH PLAYWRIGHT
THE OTHER COMMON
catastrophic cause of sudden death during the early years of cardiac surgery was surgically induced heart block. Annie Brown, Walt Lillehei’s poster child, had a minute of transient heart block, but in many of his early surgeries, it was permanent and ended in his patient’s death. In heart block the electrical impulse traveling from the atrium is blocked before it reaches the ventricle. The ventricle’s backup electrical system takes over, but at a much slower rate, usually around thirty beats per minute. At this rate the victim typically loses consciousness, and death often follows.
Paul Zoll was a consummate Boston physician, a graduate of Boston Latin School who matriculated to Harvard College and then Harvard Medical School, where he graduated summa cum laude. Slight and wiry, brilliant and inquisitive, he was the quintessential East Coast intellectual, disinclined to suffer fools. Swamped by his white coat, with huge ears, a prominent forehead, and a bald pate, my immediate impression of this intellectual giant was “elfin.” Given his stern reputation, I was wise enough to keep that description to myself until today.
During the war, Zoll was the cardiologist for the 160th U.S. Army Station Hospital—the military hospital where Dwight Harken was making his surgical breakthrough. Zoll was the sole coauthor on Harken’s landmark publication describing shrapnel extraction surgery. Perhaps Zoll’s mind drifted as he stood at the operating table watching the drama of Harken’s shrapnel extraction, because it was here that he made the trivial observation which would become the spark that solved heart block. In Harken’s operating room, as he stared down aghast at chests ripped open by explosives, Zoll noted that the esophagus, which passes just behind the heart on its way from the mouth to the stomach, abuts on the heart. It was an observation of no conceivable relevance at the time, but as we shall see, it was an image that was critical to Zoll’s development of pacemakers, the solution to heart block.
Today we have an entire subspecialty of cardiology devoted to just the heart’s electrical system, called electrophysiology. At the end of World War II, however, pacemakers and defibrillators, the yin and the yang of an electrophysiologist’s practice, did not yet exist. The pacemaker, like the defibrillator, sprang from cardiac surgeons’ despair at seeing heart block suddenly appear in a heart too good to die.
* * *
I HAVE SEEN
pacemakers save innumerable lives, but I know of no story that compares to the one related by Major Robert Eckart about a thirty-year-old soldier who sustained devastating chest trauma from an improvised roadside explosive device during combat in Iraq. When he arrived at the Ibn Sina 28th Combat Support Hospital (CSH), in Baghdad, his condition was reminiscent of the soldiers Dwight Harken faced sixty years earlier. His upper right arm was shattered, with bone protruding from the skin, and he had an open wound on the right side of his chest wall. In addition he had no detectable pulses in his right leg. X-ray images of his chest and abdomen by computed tomography showed metal shell fragments in his right lung with a pool of blood between the lung and right chest wall, injury to the heart’s right atrium, and another fragment in his abdomen in a branch of the aorta leading to his right leg.
Surgeons Robert Stewart and Edward Falta faced mind-boggling challenges. As they opened the pericardial sac which surrounds the heart, blood gushed out. The soldier had not died from the penetrating wound of the heart because, like Wilhelm Justus in Frankfurt a century before him, it had been sealed off by the pericardial sac surrounding it. Stewart and Falta sewed up the tear in the right atrium where a fragment had entered the heart. But where the heck was the shell fragment? It wasn’t in the heart! Astonished, they traced the fragment’s path. After penetrating the chest wall and ripping into the right atrium, it had blasted its way through the muscular wall that separates the right ventricle from the left ventricle, was then pumped into the aorta, and finally lodged in one of the aortic branches within his abdomen when it could pass no further. As they repaired the hole in the heart and extracted the shell fragment, the soldier’s heart rate suddenly fell to thirty beats per minute. Heart block!